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HomeMy WebLinkAbout1532A 1533A (8) WORKERS'COMPENSATION DECLARATION ' � I hereby affirm fhat I hare a certifim�P of conseN fo self APPLICATION F4R COMBINATION SWIMMING POOL PERMIT insure,or a cerlificate of Workers'Com ensa�ion Insuronce, or a certilled copy+hereof(Sec.3800,La6.C.) •snzoe � `7 /'` � I �.�}-rir{ CE07619lBal �L GL � Golicy No. ompany i COUNTY OF LOS ANGELES BUIIDING AN�SAFETY � Cer7ified copy is hereby furnished. � . FOR APPIICANT TO FILL IN sunoiNc �a Certified copy is filed wi�h�the county bu�lding inspec• ADDRE55 tion departmeni. BUIIDING q . ' ADDRESS � UI LOCALITY / Date Appliconl p NE4REST CERTIFICATE OF EXEMPTION FROM WORKERS' -� Cltt W�'Lhl�l..:1 ZiP �17Qj [ CROSSST. COMVENSATION INSURANCE SIZEOF ASSESSOR TRA ` LOT l0T NO. � MAP BOOK PAGE PARCEL (Thia s�ction n�not bo coropl.Nd if th�p�rmlt i:for on� n O TEL�Lf USE ZONE NJ+P � hundr�d dollan(5100)or I�sa.) OWNER ��-(�y�� �C1R NO.�]-/�'�QZ NO. � � / /"� I cer�if thot in the erformance of�he work for which thiz :� 57ECinl permit�5 issued,I sholl not employ any person in ony manner ADDRESS � � L. ` CONOITIONS � �' so as to bewme subject to Ihe Workers'Compe�sotion Lows. - DISTRICT STATISTICAL C1A55 OCESSED BV ' QTY ZIP CO Dafe Applitanf nRCNITECTOR /� '1' TEt. q ClAS5N0..� NOTICE 70 APPLICANT: If, afler mpking ihis Certifica�e of ENGINEER �.� 3'Jt7�v�, NO.�d���Z-1� � / Exemption, you should become subject to the Workeri , e, /vMUA710N Compensotion provisions of Ihe Labor Code,you must forlh- AD�RE55 11�Z-L , �4; ' �`/n � VALIDATION inc �omply ith such provisions or this perm�l shall be D� TE�• S deemed revoked. � CONTRACiOR CXLtC ���N i I NO. 2� LICENSED CONTRACTORS DECLARATION ' ���' ADDRESS ' L_ (M I L N���� ' I hereby affirm�hot I om licensed under provisions of Chopter 9 . ��� f . �commencing wifh$eUion 7000)of Division 3 of Iha Business ��Ty _ U �� �'� ��qu �� - and Professions Code,and my license is in full force and effecl. DESCRiPfiO OF WORK � � �21 �\ y/� FINAI .�� � License Numbe�����•Class� SWIMMING POOI . � DATE 6�a� , `1 " "- � �=' V` �i��11� � SPA � � FIHAI � � ' t �a m.• a %� O GontraUor� �' are � ' � 50.FT. � � ' V � I am exempt onder Sec. SiZE �QQ 6Y � ' ":i� `� O ' 8.8P.C.for this reason .ELECTRICAL : . . /� ,� . . �..L_� " ° ' .. ��,,� i�? ~ Dote: ' e �.!7 i `JV/ . 0 5.� h—��:�; GL W Si noture Steal 8 Condoit Bonding �s�CQ�G� � � 9 Conduits,Conductors,Eqoipment ��u�, � - `� r-�i� Z SINGLE FAMILY �',, � — HOME OWNER-BUILDER DECLARATION PLUMBING � � • � -. - . I hereby offirm tha�I am ezempt from the Controcror's license � � f+ . e . �, .�� Law for the following reason(Section 7031.5, Business ond P_T�a ' . , Professions Code): Gos Sysiem � � ` � f;:` �U � I,os owner of iha properly,will do the plumbing pnd Anti-Syphon � � � , '� < � ��; electrical work.I,or my emp�oyees with woges os iheir r sole compensafion,or a licensed contractor will do all MECHANICAL � - oiher work ond ihe strudure is noi intended or oftered ' . ��1�1 /� ?�� for sale(Seciion 7044 86P Code). Swimming Pool Heoier -0 . CONSTRUCTION LENOING AGENCY � . �.\ ' . I here6y affirm ihat ihere is a conshuct�on lending a9ency for qpp�ICANT ' TEL. �he performance of ihe work for which this permit is issued (PRiNT) � NO. (Set.3097.C�v.C.). �, ' Lender's Name ADDRESS � lender's Address P.C.Fee S � Permil Fea �i i V V - - � - � I cer�ify ihot I hove read this appliwtion and stoie�hat the i �", � obove information is mrrect I agree to comply with oll County . . v ordinances ond State laws reloting to 6uilding, electricol, Issuon e Fee mechonicol and plum6i c ruction,and hereby aWhorize Imesiigaiion Fee / , �l h . representot� of s ounty,io enter upon �he above- � - Toml Fe6 Ll V . � . me ti n �pe for spec on purposes. � � 5 nawra of Appli<aN r Aqen � Do�e SEE REVERSE FOR E%PLANATORY LANGUAGE �. ._ . . ��_� . r_.! ' _' ; ._ _ _. .. . . . . , , aNara aovNidaa iooa � ' ' � � . .. � - . � ' Pi 15313NI7 Stl9 ' - ' . - � - !/� (1N3A 8 NOI1VJ07)N31tl3H �� �:Ml]3131VNIf 7NItlIM HJfIOtl S310N S.ND1�3dSN1 � ; ' /�NiHJlv7-ilas\ 531vo l 'JNISOl7•�l3if �aump oiod , (1H'�I3H)3JN3� . uosoa� � - ' s3aiM�:n�ai� s�y��o}-�'dg'g' '�ag�apuntdwa.�wo�� - . 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' �YPOL'�ag)s�os�o;pa�a};o�o papua�ui�ou si o�n�on��s ay� - � 11lIONO�1HOn puo'�iom ay�op��im'uoposuadwo�a�os nayy so sa6om � - - -. . .. _ yym saaAo�dwa Aw�o'A�iadoid ey�)o�aumo so'�� p SWNOi 813315 � � '+('(o05S)sm��op�- - - . . . NOLLv�ot po�puny on�1 uoyi oiow�ou�0 6��ouad pnp o oi Juo� • ' . �-... •qddo ey�ai�elq�s iiw�ad o�o��uo�qddo Aua.tq S'It0[ . � . � , � � � � ; . 801�3dSNl .31Va NOIL�3dSNI uoipas }o uo��o�oln Auy �uo��dwaxo pa6apo�eyi;�of � ' � ' � � � s�seq ay�puo wo��a�ay��diu�na si oy�oy{�o(epo)suo�s _ � � . • � - ,. � -se�o�d puo ssouisng ey{�o,�uolsl^fQ}o(OOOL uo��nas. ' y�rm 6upuawwoa)(6 Jo�doy�)mo7 esua»7 sJo�oo��uo� . ' � ' - � - , ey�jo suo�s�no�d oy�o��uonsmd pesua�q sr ey-loy!luaw ' � -e�o�s paubis o aP1 0���w�ad ymrio�Juooqddo ay�za��n6 - _ .. � . � � , , , -e�os�o,'o�uonss�s��o��oud �3m��n��s Auo��oda��o - - - •ysi�ouiap•eno�dwi•�aqo•��n��suo�o+�im�ad o sai�nba� . , ' , e�op� •oN� oyoa •oN y»ym.(�uno��0 6�p Auy:opo)suoiste�o�d pua ssau�sng - � - (S'lEOL '»S)� uosooi 6u�Mopo��oy� �o� �mo��esua�7j , poAoiddy s�opoi�uo�ay�woiy ldwexe wo�1oy�w�i��o Aqa�ay � pownjey • (ol N011h'21V1�30 21301If1H-?13NM0 . S310N S.MOL'J�dSNI 1NV]Ilddtl Ol SNtlld